Tax file number declaration

This declaration is NOT an application for a tax file number. Please print neatly in BLOCK LETTERS and use a BLACK or DARK BLUE pen. Print X in the appropriate boxes. Please ensure you read all the instructions prior to completing this declaration.

PAYER'S copy

www.ato.gov.au

Section A – to be completed by PAYEE

1

Your tax file number (TFN)

OR I have made a separate application/enquiry to the Tax Office for a new or existing TFN.

refer to the cover for

privacy information

Full-time

Part-time

Casual

Labour

employment

employment

employment

hire

7

On what basis are you paid? (Select one only.)

Superannuation pension or annuity

OR I am claiming an exemption because I am under 18 years of age and do not earn enough to pay tax.

8

Are you an Australian resident for tax purposes?

Yes

No

If ‘No’, you must answer ‘No’ at question 9.

2

OR I am claiming an exemption because I am a pensioner.

Do you authorise your payer to give your TFN to the trustee of your superannuation fund or to your retirement savings account (RSA) provider?

Yes

No

9

Do you wish to claim the tax-free threshold from this payer? NOTE: If you have more than one source of income and currently claim the tax-free threshold from another payer, DO NOT claim it now.

Yes

No

If ‘No’, you must answer ‘No’ at questions 10 and 11 unless you are a non-resident claiming a Senior Australians tax offset or a zone tax offset respectively.

3 Your name Surname or family name

Title:

Mr

Mrs

Miss

Ms

10

Are you claiming a reduced rate of withholding for either family tax benefit or Senior Australians tax offset?

Yes

If ‘Yes’, obtain a Withholding declaration from your payer, but only if you are claiming the tax-free threshold from this payer. If you have more than one payer, see page 3 of the instructions.

No

First given name

11

Are you claiming a zone, dependent spouse or special tax offset?

Yes

If ‘Yes’, obtain a Withholding declaration from your payer.

No

Other given names

4

If you have changed your name since you last dealt with the Tax Office, show your previous family name

12

(a) Do you have an accumulated HECS debt? Yes If ‘Yes’, your payer will withhold additional amounts to cover your anticipated compulsory repayment(s).